Substance/Medication-Induced Obsessive-Compulsive and Related Disorder
DSM-5 Diagnostic Criteria A'''. Obsessions, compulsions, skin picking, hair pulling, other body-focused repetitive behaviors, or other symptom characteristic of the obsessive-compulsive and related disorders predominate in the clinical picture. '''B. There is evidence from the history, physical examination, or laboratory findings of both (1) and (2): # The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication. # The involved substance/medication is capable of producing the symptoms in Criterion A. C'''. The disturbance is not better explained by an obsessive-compulsive and related disorder that is not substance/medication-induced. Such evidence of an independent obsessive-compulsive and related disorder could include the following: * The symptoms precede the onset of the substance/medication use. * The symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication. * There is other evidence suggesting the existence of an independent non-substance/medication-induced obsessive-compulsive and related disorder (e.g., a history of recurrent non-substance/medication-related episodes). '''D. The disturbance does not occur exclusively during the course of a delirium. E'''. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. '''Note: This diagnosis should be made in addition to a diagnosis of substance intoxication or substance withdrawal only when the symptoms in Criterion A predominate in the clinical picture and are sufficiently severe to warrant clinical attention. Note: If a mild substance use disorder is comorbid with the substance-induced obsessive-compulsive and related disorder, the clinician should record "mild substance use disorder" before the substance-induced obsessive-compulsive and related disorder (e.g., "mild cocaine use disorder with cocaine-induced obsessive-compulsive and related disorder"). If a moderate or severe substance use disorder is comorbid with the substance-induced obsessive-compulsive and related disorder, the clinician should record "moderate substance use disorder" or "severe substance use disorder," depending on the severity of the comorbid substance use disorder. If there is no comorbid substance use disorder (e.g., after a one-time heavy use of the substance), then the clinician should record only the substance-induced obsessive-compulsive and related disorder. Specify if: * With onset during intoxication: If the criteria are met for intoxication with the substance and the symptoms develop during intoxication. * With onset during withdrawal: If criteria are met for withdrawal from the substance and the symptoms develop during, or shortly after, withdrawal. * With onset after medication use: Symptoms may appear either at initiation of medication or after a modification or change in use. Recording Procedures The name of the substance/medication-induced obsessive-compulsive and related disorder begins with the specific substance (e.g., cocaine) that is presumed to be causing the obsessive-compulsive and related symptoms. In cases in which a substance is judged to be an etiological factor but the specific class of substance is unknown, the category "unknown substance" with no comorbid substance use should be used. While recording the name of the disorder, the comorbid substance use disorder (if any) is listed first, followed by the word "with," followed by the name of the substance-induced obsessive-compulsive and related disorder, followed by the specification of onset (i.e., onset during intoxication, onset during withdrawal, with onset after medication use). For example, in the case of repetitive behaviors occurring during intoxication in a man with a severe cocaine use disorder, the diagnosis is severe cocaine use disorder with cocaine-induced obsessive-compulsive and related disorder, with onset during intoxication. A separate diagnosis of the comorbid severe cocaine use disorder is not given. If the substance-induced obsessive-compulsive and related disorder occurs without a comorbid substance use disorder (e.g., after a one-time heavy use of the substance), no accompanying substance use disorder is noted (e.g., amphetamine-induced obsessive-compulsive and related disorder, with onset during intoxication). When more than one substance is judged to play a significant role in the development of the obsessive-compulsive and related disorder, each should be listed separately. Differential Diagnosis Substance intoxication Obsessive-compulsive and related disorder symptoms may occur in substance intoxication. The diagnosis of the substance-specific intoxication will usually suffice to categorize the symptom presentation. A diagnosis of an obsessive-compulsive and related disorder should be made in addition to substance intoxication when the symptoms are judged to be in excess of those usually associated with intoxication and are sufficiently severe to warrant independent clinical attention. Obsessive-compulsive and related disorder (i.e., not induced by a substance) Substance/medication-induced obsessive-compulsive and related disorder is judged to be etiologically related to the substance/medication. Substance/medication-induced obsessive-compulsive and related disorder is distinguished from a primary obsessive-compulsive and related disorder by considering the onset, course, and other factors with respect to substances.medications. For drugs of abuse, there must be evidence from the history, physical examination, or laboratory findings for use or intoxication. Substance/medication-induced obsessive-compulsive and related disorder arises only in association with intoxication, whereas a primary obsessive-compulsive and related disorder may precede the onset of substance/medication use. The presence of features that are atypical of a primary obsessive-sompulsive and related disorder, such as atypical age at onset of symptoms, may suggest a substance-induced etiology. A primary obsessive-compulsive and related disorder diagnosis is warranted if the symptoms persist for a substantial period of time (about 1 month or longer) after the end of the substance intoxication or the individual has a history of an obsessive-compulsive and related disorder. Obsessive-compulsive and related disorder due to another medical condition If the obsessive-compulsive and related disorder symptoms are attributable to another medical condition (i.e., rather than to the medication taken for the other medical condition), obsessive-compulsive and related disorder due to another medical condition should be diagnosed. The history often provides the basis for judgement. At time, a change in the treatment for the other medical condition (e.g., medication substitution or discontinuation) may be needed to determine whether or not the medication is the causative agent (in which case the symptoms may be better explained by substance/medication-induced obsessive-compulsive and related disorder). If the disturbance is attributable to both another medical condition and substances use, both diagnoses (i.e., obsessive-compulsive and related disorder due to another medical condition and substance/medication-induced obsessive-compulsive and related disorder) may be given. When there is insufficient evidence to determine whether the symptoms are attributable to either a substance/medication or another medical condition or are primary (i.e., attributable to neither a substance/medication nor another medical condition), a diagnosis of other specific or unspecified obsessive-compulsive and related disorder would be indicated. Delirium If obsessive-compulsive and related disorder symptoms occur exclusively during the course of delirium, they are considered to be an associated feature of the delirium and are not diagnosed separately.